motivational interviewing: project elicit · getting your basic skills down: rowing the boat...
TRANSCRIPT
Motivational Interviewing: Project ELICIT
Brian Burke, PhD; Bill Miller, PhD;
Terri Moyers, PhD; Carolina E. Yahne, Ph.D.
November 17-18, 2009
Albuquerque, NM
PRE-WORKSHOP MI QUIZ (HO 1)
Please take a few minutes to fill out the
Borg The Dog
Presents…
The Six Stages of Change
1) 1) PrecontemplationPrecontemplation
Change? What change?
Perhaps more exercise would do me good.
2) Contemplation2) Contemplation
I’ll gather some info and decide what changes to make.
3) Preparation3) Preparation
Let’s play ball – I’m ready to go!!!
4) Action4) Action
Look at me – I’m still ready for more!!!
5) Maintenance5) Maintenance
I guess you can’t really teach an old dog new tricks…
6) Relapse6) Relapse
How do people change?
Relapse
Pre-contemplation
Contemplation
Preparation
Maintenance
Action
PERMANENT EXIT
ENTER
HERE
Prochaska & DiClemente (1986)
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The Stage of Change The Stage of Change ““WheelWheel””
The Stages of Change ModelThe Stages of Change Model(Prochaska, DiClemente, & Norcross, 1982)
• When is MI most useful? (see HOs 2 & 3)
• MI focuses upon the WHY of change
• Most interventions are targeted toward the HOW…
••““He who has a He who has a whywhy to to live for can bear almost live for can bear almost any any howhow..””
–– Freddy Nietzsche Freddy Nietzsche
[Twilight of the Idols][Twilight of the Idols]
The WHYs of Change:
Resistance & Change Talk
Yellow Toadflax (Butter 'n Eggs)
Yellow Daffodils
1) Five General Principles of MI
D=develop discrepancyE=express empathyA=avoid arguingR=roll with resistanceS=support self-efficacy (confidence)
Dr. Bill Miller(MINT newsletter, 1998, vol. 5, no. 3)
• “But why does MI work? How can it be that a person who has been persisting for years in a pattern of dependent drinking or drug use despite clear negative consequences abruptly shifts that pattern after an hour or two of MI? How is it that having a single session of MI before a course of outpatient or inpatient rehabilitation program can double a person’s chances of abstinence 3 months later? The person has learned no new coping skills or conditioned responses…What theory do we have about what is going on here?”
2) How you can do MI = use your OARS!
O = open questionsA = affirmationsR = reflectionsS = summaries
Open vs. Closed Questions
• CLOSED QUESTIONS:
• Invite a short answer (not only Yes/No)– Did you drink this week?
• Ask for specific information – How many siblings do you have?
• Closed questions limit answer options
• How can you turn closed questions into open questions?– Let’s try the ones above and then our own…
Two Levels of Reflection
• Simple Reflections
– Repeat/rephrase
• Complex Reflections
– Paraphrase/metaphor
– Guess at meaning
– Reflect change talk
Reflective Listening Practice
• Reflecting instead of questioning
• In 3s, speaker talks about “something you should
know about me…” or “One problem I have lately…”
• Other 2 people are co-counselors (team up)
• Counsel speaker using only reflective statements:
– Statement with “Do you mean that…?” stem
dropped
– Inflection stays flat at end of sentence (not a
question)
3) Integrating your OARS
Rowing smoothly to shore…
Doing MI = ROW the boat!
O = open questionsA = affirmationsR = reflectionsS = summaries
Getting your basic skills down: Rowing the boat ashore…
• Please arrange yourselves in groups of 3
• 1 person plays the “client” and thinks of
“something I feel two ways about…”
• 1 person plays the “observer” and codes each
counselor statement into OARS (i.e., keep a
running tally of O, A, R, S on your handout, p.11)
• “Counselor”: Try to do MI using your OARS,
aiming for 2:1 R/S to O ratio
• End: Observer + client feedback to counselor
� This is a diagnosis of your OAR-bility!
4) Change Talk & Resistance
Tools for weeding the garden and planting flowers…
The 2 sides of ambivalence:
Resistance & Change Talk
Yellow Toadflax (Butter 'n Eggs)
Yellow Daffodils
Values exploration exercise
Roadmap of change (HO 13)
• Think of your possible change from this morning
• On the path to no change (status quo), write down what things would be like if you did not make this change (you can draw if you want)
• On the path to change (the other road), write down what things might be like if you did make the change (how would things be different?)
• Indicate where you currently are along the road
• What would you name the road?
• What’s the next step for you?
Ask-Provide-Ask
• Problem with MI: You have specific information (“advice”) to share with your clients/patients!
• In pairs, have counselor pick a target drug
• Counselor: Use A-P-A to give client info on that drug
4) Change Talk & Resistance
(continued)
Tools for weeding the garden and planting flowers…
The 2 sides of ambivalence:
Resistance & Change Talk
Yellow Toadflax (Butter 'n Eggs)
Yellow Daffodils
“Soccer Mike” video
• As you watch this video, use handout to code the change talk in this session
Readiness RulersImportance: (a) On a scale of 0-10, how important is it for you to make this change?
0-----------------------------------------------------------10(b) How come you’re a __(your #) and not a __ (lower #)? (c) What would it take for you to go from __ (your #) to __(higher #)?
Confidence: (a) On a scale of 0-10, how confident are you that you could make this change if you decided to?
0-----------------------------------------------------------10(b) How come you’re a __(your #) and not a __ (lower #)? (c) What would it take for you to go from __ (your #) to __(higher #)?
Using the Rulers:Eliciting Change Talk
• Please get into different pairs
• 1 person think of a problem behavior you might want to change but you have not yet done so…
• You can use your same change from yesterday
• Your partner will counsel you using only 2 tools:
– READINESS RULERS
– REFLECTIONS
Dr. Bill Miller
Eliciting Confidence Talk
Rolling with Resistance
• How do you see/hear resistance from
the clients you work with?
• How can resistance be a “normal”
response?
• What seems to work well in your setting
to “roll with the resistance”?
Rolling with Resistance
� Reflections
� Simple
� Amplified
� 2-sided
� Shifting focus
� Emphasize choice & control
� Agreement (+/- a twist)
Rolling with Resistance:
“Rounder” video & exercise
• As we watch the video, we will pause it to:
– Label wrestling vs. dancing
– Label rolling with resistance techniques used
– Respond before Dr. Moyers does!
• Start after first minute with a 0-10 rating where 0=wrestling and 10=dancing, then rerate every time the number moves and note what happened to move it (what Dr. Moyers did)…
Rolling with Resistance
• BP=Batting Practice
• Please arrange yourselves in 3 groups
• In your group, 1 person bats at a time
• Anyone else in group can throw a “pitch” –call out a resistant statement that a client might say
• Batter swings at the pitch by rolling with the resistance and then gets ready for next pitch
• After 3 swings, switch batters!
Putting it all together…
Remember: ROW the boat!
O = open questionsA = affirmationsR = reflectionsS = summaries
Team Practice
• Please get into 2 large groups
• Let’s generate a client together
• 1 counselor and 1 client in each group
• Coding teams
– OARS
– Simple vs. complex reflections
– 4 basic principles of MI
• Everyone else: consult with counselor & tell him/her what to say in order to do MI with the client…
5) CHANGE/ACTION PLANS
How do you know when it’s time to make a change or action plan?
Action Plan Questions (Os)
• What are your goals?
• What 1st steps could you take to reach these
goals?
• What will it look like when you reach your goals?
• Who can help you with your plan?
• What might get in your way? (obstacles)
• How would you deal with these obstacles?
• Let’s try this in pairs with your possible change from earlier
6) PUTTING MI INTO YOUR PRACTICE
How will you use MI in your work?
Please form groups based around similar work settings and discuss this question, including what might get in your way from doing MI in your setting
A taste of Motivational InterviewingA taste of Motivational Interviewing43
Speaker’s Topic
• Something about yourself that you – want to change
– need to change
– should change
– have been thinking about changing
but you haven’t changed yet
i.e. – something you’re ambivalent about
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A Taste of MI:Conversation with one speaker and one listener
Listener
• Listen carefully with a goal of understanding the dilemma
• Give no advice.
• Ask these four open questions and listen with interest:
Why would you want to make this change?
How might you go about it, in order to succeed?
What are the three best reasons to do it?
On a scale from 0 to 10, how important would you say it is for you to make this change?
• Follow-up: And why are you at __ and not zero?
• Give a short summary/reflection of the speaker’s motivations for change
• Then ask: “So what do you think you’ll do?” and just listen
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Common Human Reactions to Being Listened to
• Understood
• Want to talk more
• Liking the counselor
• Open
• Accepted
• Respected
• Engaged
• Able to change
• Safe
• Empowered
• Hopeful
• Comfortable
• Interested
• Want to come back
• Cooperative
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Would you rather work with these people . . . . .
or these?
• Angry, agitated
• Oppositional
• Discounting
• Defensive
• Justifying
• Not understood
• Not heard
• Procrastinate
• Afraid
• Helpless, overwhelmed
• Ashamed
• Trapped
• Disengaged
• Not come back – avoid
• Uncomfortable
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Sentence Stems
• I learned . . . .
• I was surprised . . .
• Now I know that . . .
• I can’t wait to try . . .
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